Australian guideline on management of diabetes-related foot infection: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease
Diabetes Feet Australia · 2022 · Australia
Source and licence
- Authors
- Robert J. Commons, James Charles, Jane Cheney et al.
- Title
- Australian guideline on management of diabetes-related foot infection: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease
- Journal
- Journal of Foot and Ankle Research, 2022
- Licence
- CC BY 4.0
- Changes
- Verbatim excerpts; formatting adapted
Full text retrieved 2026-10-27 from Europe PMC · PMC9178854
Licence statement of the original publication
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This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.
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Recommendations
Verbatim, with grade of recommendation or strength of consensus where given.
Question one part a
- Recommendation 1aDiagnose a soft tissue diabetes-related foot infection clinically, based on the presence of local or systemic signs and symptoms of inflammation.GRADE strength of recommendation: Strong; Quality of evidence: low
- Recommendation 1bAssess the severity of any diabetes-related foot infection using the International Working Group on the Diabetic Foot / Infectious Diseases Society of America classification scheme.Strong; moderate
Monitoring considerations
- The panel suggests that services use the IWGDF classification scheme to categorise patients in their service to assist with subsequent planning and management decisions.
Question one part b
- Recommendation 2Consider hospitalising all persons with diabetes and a severe (grade 4) foot infection and those with a moderate (grade 3) infection that is complex or associated with key relevant morbidities.Strong; low
Geographically remote people
- The panel noted there is a disparity across Australia in regard to access to multidisciplinary teams (MDT)-High Risk Foot Services or centres with specialist surgical services to manage patients with some moderate (grade 3) and severe (grade 4) diabetes-related foot infections requiring urgent or elective surgical intervention. This is particularly pertinent for individuals in remote areas where the adoption of more out-patient based managements may be preferred such as chairside surgeries or the utilisation of out-patient parenteral antibiotic therapy.
Question two part a
- Recommendation 3In a person with diabetes and a possible foot infection for whom the clinical examination is equivocal or uninterpretable, consider ordering an inflammatory serum biomarker, such as C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and perhaps procalcitonin, as an adjunctive measure for establishing the diagnosis.Weak; low
Question two part b
- Recommendation 4As neither electronically measuring foot temperature nor using quantitative microbial analysis has been demonstrated to be useful as a method for diagnosing diabetes-related foot infection, we suggest not using them.Weak; low
Question three
- Recommendation 5In a person with diabetes and suspected osteomyelitis of the foot, we recommend using a combination of the probe-to-bone test, the erythrocyte sedimentation rate (or C-reactive protein and/or procalcitonin), and plain X-rays as the initial studies to diagnose osteomyelitis.Strong; moderate
- Recommendation 6aIn a person with diabetes and suspected osteomyelitis of the foot, if a plain X-ray and clinical and laboratory findings are most compatible with osteomyelitis, we recommend no further imaging of the foot to establish the diagnosis.Strong; low
- Recommendation 6bIf the diagnosis of osteomyelitis remains in doubt, consider ordering an advanced imaging study, such as magnetic resonance imaging (MRI) scan, 18F-FDG-positron emission tomography (PET)/computed tomography (CT) or leukocyte scintigraphy (with or without CT).Strong; moderate
- Recommendation 7In a person with diabetes and suspected osteomyelitis of the foot, in whom making a definitive diagnosis or determining the causative pathogen is necessary for selecting treatment, collect a sample of bone (percutaneously or surgically) to culture clinically relevant bone microorganisms and for histopathology (if possible).Strong; low
Question four
- Recommendation 8aCollect an appropriate specimen for culture for almost all clinically infected wounds to determine the causative pathogens.Strong; low
- Recommendation 8bFor a soft tissue diabetes-related foot infection, obtain a sample for culture by aseptically collecting a tissue specimen (by curettage or biopsy) from the ulcer.Strong; moderate
Question five
- Recommendation 9Do not use molecular microbiology techniques (instead of conventional culture) for the first-line identification of pathogens from samples in a patient with a diabetes-related foot infection.Strong; low
Question six
- Recommendation 10Treat a person with a diabetes-related foot infection with an antibiotic agent that has been shown to be effective in a published randomised controlled trial and is appropriate for the individual patient. Some agents to consider include penicillins, cephalosporins, carbapenems, metronidazole (in combination with other antibiotic [s]), clindamycin, linezolid, daptomycin, fluoroquinolones, or vancomycin, but not tigecycline.Strong; high
Monitoring considerations
- The panel recommends that individual services should collaborate with their local antimicrobial stewardship team to evaluate their local antibiotic usage and compare it to similar services and centres where possible.
Question six
- Recommendation 11Select an antibiotic agent for treating a diabetes-related foot infection based on: the likely or proven causative pathogen(s) and their antibiotic susceptibilities; the clinical severity of the infection; published evidence of efficacy of the agent for diabetes-related foot infections; risk of adverse events, including collateral damage to the commensal flora; likelihood of drug interactions; agent availability; and, financial costs.Strong; moderate
- Recommendation 12Administer antibiotic therapy initially by the parenteral route to any patient with a severe (grade 4) skin and soft tissue diabetes-related foot infection. Switch to oral therapy if the patient is clinically improving and has no contraindications to oral therapy and if there is an appropriate oral agent available.Strong; very low
Summary justification
- Although the panel downgraded the quality of evidence to very low, they agreed with the IWGDF that diabetes-related foot infections were an important health problem in Australia, and that the balance of effects favoured the use of initial intravenous antibiotics for severe (grade 4) skin and soft tissue diabetes-related foot infections. It was noted that a switch to oral therapy when the patient was clinically improving was appropriate for severe (grade 4) skin and soft tissue infections. Furthermore, it was noted that in the IWGDF guidelines this recommendation was intended to relate to people with skin and soft tissue infections, sitting under a sub-heading stating this, however, this was not clear when the recommendation was read outside the context of the overall IWGDF guideline document. The panel were unsure whether the critical outcome of clinical cure of infection would be consistently valued above all other outcomes by all patients (for example some patients may prefer avoidance of amputation and long term antibiotic suppression). They noted that the recommendation was likely acceptable and feasible in the Australian setting. Detailed justifications from the panel’s full assessment are provided in Supplementary Table S1.
Future research considerations
- One of the key research priorities identified by IWGDF was whether oral antibiotic therapy alone is as effective as parenteral treatment for diabetes-related foot infections, including diabetes-related foot osteomyelitis. The panel noted a need for studies to evaluate whether all patients with severe (grade 4) infections require initial parenteral antibiotic therapy. Furthermore, they identified a need for studies to explore the duration of initial parenteral antibiotics that is needed prior to oral switch for patients with severe (grade 4) diabetes-related foot infections and the factors that influence this decision.
Question six
- Recommendation 13Treat patients with a mild (grade 2) diabetes-related foot infection, and most with a moderate (grade 3) diabetes-related foot infection, with oral antibiotic therapy, either at presentation or when clearly improving with initial intravenous therapy.Weak; low
Future research considerations
- IWGDF highlighted a need to further understand whether complete oral therapy is as effective as parenteral treatment for diabetes-related foot infections. The panel agreed that studies are needed to compare the use of complete oral therapy with initial intravenous therapy in infections of moderate (grade 3) severity and that they should assess patient outcomes.
Question six
- Recommendation 14We suggest not using any currently available topical antimicrobial agent for treating a mild (grade 2) diabetes-related foot infection.Weak; moderate
- Recommendation 15aAdminister antibiotic therapy to a patient with a skin or soft tissue diabetes-related foot infection for a duration of 1 to 2 weeks.Strong; high
Monitoring considerations
- The panel recommends that services record the duration of antibiotic treatment provided to patients to enable an audit of treatment duration by infection severity compared with the guidelines.
Question six
- Recommendation 15bConsider continuing treatment, perhaps for up to 3 to 4 weeks, if the infection is improving but is extensive and is resolving slower than expected or if the patient has severe peripheral artery disease.Weak; low
- Recommendation 15cIf evidence of infection has not resolved after 4 weeks of apparently appropriate therapy, re-evaluate the patient, and reconsider the need for further diagnostic studies or alternative treatments.Strong; low
- Recommendation 16For patients who have not recently received antibiotic therapy and have an acute infection, consider targeting empiric antibiotic therapy at just aerobic Gram positive pathogens (beta-haemolytic streptococci and Staphylococcus aureus) in cases of a mild (grade 2) diabetes-related foot infection.Weak; low
- Recommendation 17For patients who have been treated with antibiotic therapy within a few weeks, have a chronic infection, have a severely ischaemic affected limb, or a moderate (grade 3) or severe (grade 4) infection, we suggest selecting an empiric antibiotic regimen that covers Gram positive pathogens, commonly isolated Gram negative pathogens, and possibly obligate anaerobes in cases of moderate (grade 3) to severe (grade 4) diabetes-related foot infections. Then, reconsider the antibiotic regimen based on both the clinical response and culture and sensitivity results.Weak; low
- Recommendation 18Empiric treatment aimed at Pseudomonas aeruginosa is not usually necessary but consider it if P. aeruginosa has been isolated from cultures of the affected site within the previous few weeks, or in tropical/subtropical climates (at least for moderate [grade 3] or severe [grade 4] infection).Weak; low
- Recommendation 19Do not treat clinically uninfected foot ulcers with systemic or local antibiotic therapy with the goal of reducing the risk of infection or promoting ulcer healing.Strong; low
Question seven part a
- Recommendation 20Non-surgeons should urgently consult with a surgical specialist in cases of severe (grade 4) infection or of moderate (grade 3) infection complicated by extensive gangrene, necrotising infection, signs suggesting deep (below the fascia) abscess or compartment syndrome, or severe lower limb ischaemia.Strong; low
- Recommendation 21aIn a patient with diabetes and uncomplicated forefoot osteomyelitis, for whom there is no other indication for surgical treatment, consider treating with antibiotic therapy without surgical resection of bone.Strong; moderate
Summary justification
- The panel agreed with the IWGDF that there was a moderate quality of evidence and a strong (strength of) recommendation for the recommendation. The recommendation was considered compatible with patients’ values, applicable to the Australian context and feasible in primary, secondary and tertiary healthcare settings in Australia. The panel noted that according to the exclusion criteria in the sole RCT assessing this issue [37], uncomplicated forefoot osteomyelitis should be defined as osteomyelitis without severe (grade 4) infection, and without any of the following: necrotising tissue infection, bone exposed in the base of the ulcer, kidney injury, or peripheral artery disease. Detailed justifications are described in Supplementary Table S5.
Question seven part a
- Recommendation 21bIn a patient with probable diabetes-related foot osteomyelitis with concomitant soft tissue infection, urgently evaluate the need for surgery as well as intensive post-operative medical and surgical follow-up.Strong; moderate
- Recommendation 22Select antibiotic agents for treating diabetes-related foot osteomyelitis from among those that have demonstrated efficacy for osteomyelitis in clinical studies.Strong; low
- Recommendation 23aTreat diabetes-related foot osteomyelitis with antibiotic therapy for no longer than 6 weeks. If the infection does not clinically improve within the first 2 to 4 weeks, reconsider the need for collecting a bone specimen for culture, undertaking surgical resection, or selecting an alternative antibiotic regimen.Strong; moderate
- Recommendation 23bTreat diabetes-related foot osteomyelitis with antibiotic therapy for just a few days if there is no soft tissue infection and all the infected bone has been surgically removed.Weak; low
Monitoring considerations
- The panel recommends that services record the duration of antibiotic treatment provided to patients post definitive surgery and whether tissue samples were sent from the presumed clean wound post-surgical debridement.
Question seven part a
- Recommendation 24For people with diabetes-related foot osteomyelitis that initially require parenteral therapy, consider switching to an oral antibiotic regimen that has high bioavailability after perhaps 5 to 7 days, if the likely or proven pathogens are susceptible to an available oral agent and the patient has no clinical condition precluding oral therapy.Weak; moderate
Monitoring considerations
- The panel recommends that individual services record the duration of intravenous and oral antibiotic therapy to allow comparison of patient outcomes and between services.
Question seven part b
- Recommendation 25aDuring surgery to resect bone for diabetes-related foot osteomyelitis, consider obtaining a specimen of bone for culture (and, if possible, histopathology) at the stump of the resected bone to identify if there is residual bone infection.Weak; moderate
Monitoring considerations
- The panel recommends that services record whether tissue samples were sent from the presumed clean wound post-surgical debridement.
Question seven part b
- Recommendation 25bIf an aseptically collected culture specimen obtained during the surgery grows pathogen(s), or if the histology demonstrates osteomyelitis, administer appropriate antibiotic therapy for up to 6 weeks.Strong; moderate
Question eight
- Recommendation 26For a diabetes-related foot infection, do not use hyperbaric oxygen therapy or topical oxygen therapy as an adjunctive treatment if the only indication is specifically for treating the infection.Weak; low
- Recommendation 27aTo specifically address infection in a diabetes-related foot ulcer do not use adjunctive granulocyte colony stimulating factor treatmentWeak; moderate
- Recommendation 27bTo specifically address infection in a diabetes-related foot ulcer do not routinely use topical antiseptics, silver preparations, honey, bacteriophage therapy, or negative pressure wound therapy (with or without instillation).Weak; low
Monitoring considerations
- The panel suggests that the use of such therapies should be recorded by each service and a regular evaluation performed to review patient outcomes and adverse events in those using such therapies.
Justifications summary
- Recommendation 23(a) was excluded based on substantial differences in judgements to the IWGDF for the certainty of evidence and balance of effects (Table 2) and due to inclusion of a heterogeneous population that was considered too broad for the recommendation. In addition, Recommendation 21(a) was considered to already cover the subgroup of patients where evidence exists to support a shorter duration of therapy for diabetes-related foot osteomyelitis.
Abstract
Background: Diabetes-related foot infections cause substantial morbidity and mortality, both globally and in Australia. There is a need for up-to-date evidence-based guidelines to ensure optimal management of patients with diabetes-related foot infections. We aimed to identify and adapt high quality international guidelines to the Australian context to become the new Australian evidence-based guideline for people with a diabetes-related foot infection.
Methods: Following Australian National Health and Medical Research Council (NHMRC) procedures we identified the 2019 International Working Group on the Diabetic Foot (IWGDF) guidelines as suitable for adaptation to the Australian context. Guidelines were screened, assessed and judged by an expert panel for the Australian context using the guideline adaptation frameworks ADAPTE and Grading of Recommendations Assessment, Development and Evaluation (GRADE). Judgements led to recommendations being adopted, adapted or excluded, with additional consideration regarding their implementation, monitoring and future research for the Australian context. Clinical pathways were then developed to assist implementation.
Results: Of 36 original diabetes-related foot infection IWGDF sub-recommendations, 31 were adopted, four were adapted and one was excluded. Adaption was primarily undertaken due to differences or clarification of the sub-recommendations’ intended population. One sub-recommendation was excluded due to substantial differences in judgements between the panel and IWGDF and unacceptable heterogeneity of the target population. Therefore, we developed 35 evidence-based sub-recommendations for the Australian context that should guide best practice diagnosis and management of people with diabetes-related foot infection in Australia. Additionally, we incorporated these sub-recommendations into two clinical pathways to assist Australian health professionals to implement these evidence-based sub-recommendations into clinical practice. The six guidelines and the full protocol can be found at: https://www.diabetesfeetaustralia.org/new-guidelines/.
Conclusions: A new national guideline for the diagnosis and management of people with diabetes-related foot infections were successfully developed for the Australian context. In combination with simplified clinical pathway tools they provide an evidence-based framework to ensure best management of individuals with diabetes-related foot infections across Australia and highlight considerations for implementation and monitoring.
Supplementary Information: The online version contains supplementary material available at 10.1186/s13047-022-00545-4.
Contents of the original publication
The section headings of the original.
- Background
- Methods
- Results
- Question one part a
- Recommendation 1a
- Recommendation 1b
- Subgroup considerations
- Question one part b
- Recommendation 2
- Question two part a
- Recommendation 3
- Question two part b
- Recommendation 4
- Question three
- Recommendation 5
- Recommendation 6a
- Recommendation 6b
- Recommendation 7
- Question four
- Recommendation 8a
- Recommendation 8b
- Question five
- Recommendation 9
- Question six
- Recommendation 10
- Recommendation 11
- Recommendation 12
- Recommendation 13
- Recommendation 14
- Recommendation 15a
- Recommendation 15b
- Recommendation 15c
- Recommendation 16
- Recommendation 17
- Recommendation 18
- Recommendation 19
- Question seven part a
- Recommendation 20
- Recommendation 21a
- Recommendation 21b
- Recommendation 22
- Recommendation 23a
- Recommendation 23b
- Recommendation 24
- Question seven part b
- Recommendation 25a
- Recommendation 25b
- Question eight
- Recommendation 26
- Recommendation 27a
- Recommendation 27b
- Discussion
- Recommendations summary
- Justifications summary
- Implementation considerations summary
- Subgroup considerations summary
- Monitoring considerations summary
- Future research considerations summary
- Conclusion
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